Introduction to Dissociative Identity Disorder (DID) Dissociative Identity Disorder (DID) is a fascinating disorder that is probably the least

extensively studied and most debated psychiatric disorder in the history of diagnostic classification. There is also notable lack of a consensus among mental health professionals regarding views on diagnosis and treatment. In one study involving 4 ! doctoral"level clinicians# nearly one"third believed that a diagnosis of $orderline %ersonality Disorder was more appropriate than DID. &hile most psychologists demonstrated belief that DID is a valid diagnosis# '() believed that DID either likely or definitely could be created through the therapist*s influence# and +!) indicated that DID could likely or definitely develop as a result of exposure to various forms of media (,ormier - Thelen# +..().

Description of DID
Diagnosis /ccording to the diagnostic criteria outlined in the current edition of the D01# diagnosis of DID re2uires the presence of at least two personalities# with a personality being identified as a entity having a uni2ue pattern of perception# thought# and relational style involving the both the self and the environment. These personalities must also display a pattern of exerting control on the individual*s behavior. 3xtensive and unusual loss of memory pertaining to personal information another feature of DID. Differential diagnosis generally involves ruling out the effects of chemical substances and medical (as opposed to psychological) conditions. &hen evaluating children# it is also important to ensure that symptoms are distinguishable from imaginary play (/merican %sychiatric /ssociation# 444). Prevalence & Comorbidity In clinical populations# the estimated prevalence of DID ranges from 4.! to +.4) (1aldonado# $utler# - 0piegel# 44 ). In the general population# estimates of prevalence are somewhat higher# ranging from +"!) (5ubin 6orumski# 44!). 7emales are more likely to receive a diagnosis of DID# at

a ratio of .8+ (9ewis":all# 44 ). This author also contends that the disproportionately high number of females diagnosed with DID dispels the notion that incestual abuse is largely responsible for the development of DID. :igh percentages of individuals with DID have comorbid diagnoses of %ost"Traumatic 0tress Disorder or $orderline %ersonality Disorder (;leaves# 1ay# - ,arde<a# 44+). In addition# individuals diagnosed with DID commonly have a previous diagnosis of 0chi=ophrenia. :owever# this most likely represents a misdiagnosis rather than comorbidity# due to the fact that both disorders involve experiencing 0chneiderian symptoms (ibid.). >ther possible comorbid disorders involve substance abuse# eating disorders# somatoform disorders# problems of anxiety and mood# personality disorders# psychotic disorders# and organic mental disorders (I00D# 44!)# >,D# or some combination of conversion and somatoform disorder (?aplan - 0adock# 44(). &hile the symptoms of DID are complex in themselves# the presence of multiple additional symptoms further complicates diagnosis and treatment. Client characteristics, course, & prognosis The course and prognosis of untreated DID is uncertain# and for individuals with comorbid disorders# prognosis is less favorable. >ther factors influencing a poor prognosis include remaining in abusive situations# involvement with criminal activity# substance abuse# eating disorders# or antisocial personality features. /lthough DID occurs more fre2uently in the late adolescence or early adult age groups# the average age of diagnosis is thirty# with most diagnoses occurring !"+4 years after the onset of symptoms. / risk factor involves having first"degree relatives who have received diagnoses of DID (?aplan - 0adock# 44(). Risk factors >ne study found that the risk of developing a dissociative disorder (DD) increased seven times with a child*s exposure to trauma. / later diagnosis of DD was twice as likely when the child*s mother had experienced trauma within two years of the child*s birth (%as2uini# 9iotti# 1a==otti# 7assone# -

%icardi et al. 44 ). Dissociative Identity Disorder is linked to childhood abuse in .!".() of the cases (?orol# 44(). :owever# other factors in addition to a history of abuse# such as disorgani=ed or disoriented attachment style and a lack of social or familial support best predict that an individual will develop DID (ibid). 0tudies on genetic factors contributing to DID present mixed findings. :owever# one study involving dy=ogotic and mono=ygotic twins found that considerable variance in experiences of pathological dissociation could be attributed to both shared and non"shared environmental experiences# but heritability appeared to have no effect (&aller - 5oss# +..@). /nother study utili=ing obAective ratings of dissociative behavior found that shared environmental factors had little effect in both adopted siblings and twin pairs ($ecker"$lease# et al# 444). :owever# dissociative behavioral correlations of r B 4. + for fraternal twins and r B 4.C4 for identical twins suggests the presence of a genetic effect. /s this study did not specifically investigate pathological dissociation# more research is needed to determine if the genetic tendency to experience dissociation varies according to type of dissociation (pathological or non"pathological)# and whether trauma influences the pathological development of a pre"existing tendency to dissociate. Multicultural considerations 0amples of participants from the Dnited 0tates# ,anada# the Eetherlands# Eorway# and Turkey found a similar prevalence estimates (?luft - 7oot# +...). :owever# prevalence in India# ;ermany# and Fapan is much lower (7uAii# 0u=uki# 0ato# 1uraka# - Takahashi# +..(). / study conducted with inpatient# outpatient# and the general population in ,hina found prevalence rates of 4.!# 4.'# and 4.4)# respectively (Giao# et al.# 44C). 7actors related to individualistic and collectivistic cultures may contribute to the prevalence and etiology of DID. /ccording to 7uAii et al.# not only are reports of DID in Fapan are far more scarce than in Eorth /merica# but other differences also exist. &hile most Eorth /mericans participants with DID were physically or sexually abused in childhood# Fapanese participants

diagnosed with DID were far less likely to have experienced physical or sexual abuse. The Eorth /merican participants in this study also had nearly three times as many alter personalities as Fapanese participants.

Treatment of Dissociative Identity Disorder

Psychotherapy /lthough the ultimate goal of treatment is integrated functioning of the alter personalities (I00D# 44!)# the presence of multiple comorbid disorders# experiences of trauma# and safety concerns make a comprehensive treatment plan necessary. The International 0ociety for the 0tudy of Dissociation (I00D) published some basic guidelines to aid clinicians in treating DID. Treatment most commonly follows a framework of H+) safety# stabili=ation and symptom reduction# ) working directly and in depth with traumatic memories# and ') identity integration and rehabilitationI (p. (.). / study involving (4 outpatient participants (.() DID diagnosis) from five different races (,aucasian# /frican /merican# :ispanic# /sian# and >ther) demonstrated the effectiveness of a similar five"phase model in reducing symptoms of dissociation. /s might be expected from successful treatment# clients in later phases of treatment reported less self"harming behavior# symptom reduction# and more positive behavior than clients in stage +# as indicated by scores on the Dissociative 3xperiences 0cale II# the %osttraumatic 0tress ,hecklist",ivilian# and the 0ymptom ,hecklist".4" 5evised ($rand# et al.# 44.). &hile elements of each phase occur throughout treatment# these phases describe the dominant concerns of therapy during the stages of treatment. $ecause of the intense feelings experienced as a result of trauma# individuals with DID may behave in ways that facilitate exploitation or are dangerous to themselves or others. Thus# a primary goal for treatment is to manage these behaviors and teach impulse control with some form of cognitive or behavioral therapy. 3ven when amnesia exists between alters# therapists should hold the client responsible for behaviors of all alters. Therapists should also reali=e that some clients do not desire fusion or

integration of their personalities. In this case# the goal of treatment would involve working towards cooperative functioning of alters. In working with alters# therapists should view alters not as problems to be removed# but as the client*s creative response to trauma. Identifying relationships between alters and communicating with alters directly are strategies useful in treating DID. 5e2uesting that the client listen inwardly to alters may facilitate necessary discussion among alters and between the therapist and client (I00D# 44!). Medication Eo randomi=ed trials have been conducted to compare the effectiveness of various theoretical orientations or medications in treating DID. :owever# a survey of psychiatrists treating DID found that the most favored treatment methods involved individual therapy# anxiolytics# and antidepressants (0no - 0chalken# +...). In addition to these drugs# carbama=apine for use electroencephalograph abnormalities# pra=osin for nightmares# and naltrexone for self"inAurious behavior might be helpful (?aplan - 0adock# 44(). /lthough research involving pharmacotherapy for DID is scarce# two studies involving dia=epam and perospirone seem promising. 7ollowing unsuccessful treatment with antidepressants and tran2uili=ers# >kugawa# Eobuhara# ?itashiro# and ?inoshita ( 44!) examined the effects of treating DID with perospirone# a medication originally intended for the treatment of schi=ophrenia. The clinical features of this case involve two alternate personalities# who presented as a male ( ' years) and a female (+@ years). The client (host) was female and '4 years old# and had been diagnosed with DID for +' years. During presentation of the young female personality# the client reported hearing the male alter# which was her primary symptom# along with anxiety and identity dissociation. The client experienced remission of anxiety and hallucinatory symptoms after a month of treatment with perospirone. Treatment was continued for ! months# and medication was gradually reduced over a period of . months. /t the time of writing# the client had experienced remission of dissociative symptoms for + year. The results of this case study seem remarkable#

especially because use of medication alone was responsible for drastic and sustained improvement in functioning# and continued use of medication was not re2uired to maintain remission of symptoms. /nother case study conducted by $allew# 1organ# and 9ippmann ( 44') suggests that dia=epam*s anxiety"reducing properties may prove especially useful for assisting in memory retrieval in cases of DID where memories contain traumatic materials. In this study# dia=epam was used to successfully facilitate memory retrieval in an amnestic client who was unable to recall his location or identity. The authors of this study concluded that HIntravenous dia=epam is aneffective# safe intervention to consider for facilitation ofmemory retrieval in amnestic patients#I and DID can involve some degree of amnesia (p. '4@). :owever# because the efficacy and safety of dia=epam has not been demonstrated in the treatment of an ade2uate number of cases of dissociative disorders# it is difficult to generali=e these findings or assess the appropriateness of this treatment. 1edication is generally applicable to secondary features and comorbid disorders# and not DID itself. Integrative treatment plan ,onsidering the complexity of DID and the lack of conclusive research on treatment methods# the best treatment approach would involve an integrative style. The use of medication for anxiety and trauma"related symptoms and the phase approach allows for immediate treatment of distressing symptoms# flexibility# and a continual evaluation of progress. Depending on which theoretical orientation is more appropriate# various psychotherapeutic modalities can be used to address specific problems as necessary. Inflexibly using one approach may hinder successful treatment# especially because DID often involves comorbid disorders that may need to be considered separately. In addition to integrative individual treatment# ?aplan and 0adock ( 44() suggest that familiarity with systems theory and somatoform disorders may be helpful to the therapist in understanding the client*s somatic symptoms and relationships between alters.

$ecause research supports the importance of social support as a preventative factor# all efforts should be made to discover sources of support for the client once stability is achieved. ;roup psychotherapy is one way to achieve this goal. /dvantages of group therapy include reducing isolation related to a diagnosis of DID# the opportunity to interact with both genders in heterogeneous groups# and an accepting peer group that replaces the secrecy and isolation surrounding childhood abuse. ;roup therapy provides clients with the opportunity observe others and learn the purpose of alters# and hope for their own recovery as others in the group improve ($uchele# +..' There are advantages and disadvantages to every treatment method# and it is the responsibility of the therapist to explore feasible options and empower clients in their recovery.

Research and Conclusions

Current research 5esearch trends currently focus on neurobiological and psychobiological factors uni2ue to this disorder. 7or example# one study investigated the differences between alters who have access to traumatic memories and alters who suppress such information. The results indicate that different alters demonstrate differences in emotional# sensori"motor# cardiovascular# and regional cerebral blood flow in response to traumatic memories (5einders# et al.# 44C). /nother study sought to apply known findings about related disorders to DID. $ecause individuals diagnosed with disorders involving an etiology of stress (e.g.# %ost"Traumatic 0stress Disorder# $orderline %ersonality Disorder# 1aAor Depressive Disorder with childhood trauma) have demonstrated a reduction in hippocampal volume# the authors of this study used magnetic resonance imaging and volumetric analyses to determine if any relationship also existed between DID and reduced hippocampal volume. 5esults indicated that the volume of the hippocampus of participants with DID was +.. ) smaller and the amygdala was '+.C) smaller than normal controls (Jermetten# 0chmahl# 9indner# 9oewenstein# - $remner# 44C).

>ther studies have discovered findings that are relevant to the relationship between trauma and memory in DID. / case study investigating the neural correlates of switching between alters used functional magnetic resonance imaging to study changes in the brain during switching. The results indicated that during switching to the alternate personality# the client*s bilateral hippocampus was inhibited# as well as the right parahippocampal gyrus# right medial temporal lobe# globus pallidus# and substantia nigra. :owever# during transition to the host personality# the right hippocampus demonstrated evidence of increased activation# with no inhibition in any brain structures (Tsai# ,ondi# &u# - ,hang# +...). These findings contribute to an understanding of amnesia between alters# since regions of the brain involved in memory are either inhibited or activated. >ther research supports the idea that alters develop to protect the host from unpleasant thoughts and memories involving trauma and abuse. /utobiographical memories may differ between alter personalities# allowing the host to retain positive memories while alters contain negative traumatic memories ($ryant# 44!). / study investigating directed forgetting found that Hdissociative patients showed directed forgetting between states# but not within the same identity stateI (p. 4+). This study clarifies the mechanism and function of memory in various dissociative states and helps explain why trauma might result in the development of alters. %ushing threatening material out of consciousness can then be facilitated by a switch from one state of consciousness to another (3l=inga# %haf# /rdon# - van Dyck# 44'). Future direction &hile clinicians now understand more about DID than in the past# additional research is needed to clarify and further investigate the nature of DID. The research that has been completed on this disorder still leaves many 2uestions unanswered. 7or example# future research should further examine risk factors# and clarify how genetic and environmental factors contribute to this disorder. 1ore studies should determine the nature of the physical and psychological differences evident among alters# how they

develop# and their significance. %sychopharmacological studies are needed to determine which medications work best# and why they are effective. 1ulticultural research is necessary to determine how sociocultural factors affect the development and clinical presentation of DID. /dditional research in this area will not only benefit individuals with DID and their families# but also the research and clinical psychology community as a whole. ;aining an improved understanding of Dissociative Identity Disorder involves more than the categori=ation of another mental disorder. Increased knowledge in this area also contributes to an improved understanding of the nature of consciousness and the mind"brain relationship# as well. References /merican %sychiatric /ssociation. ( 444). Diagnostic and statistical manual of mental disorders (text revision). &ashington# D,8 /uthor. $allew# 9.# 1organ# K.# - 9ippmann# 0. ( 44'). Intravenous dia=epam for dissociative disorder8 1emory lost and found. Psychosomatics, 44, '4C" '4@. $ecker"$lease#?.# Deater"Deckard# ?.# Thalia 3ley# 3.# 7reyd# F.# 0tevenson# F.# - %lomin# 5. ( 444). / genetic analysis of individual differences in dissociative behaviors in childhood and adolescence. Journal of Child Psychology and Psychiatry 45(')# ! L!' . $rand# 5.# ,lassen# ,.# 9anius# 5.# 9oewenstein# 5.# 1cEary# 0.# %ain# ,.# %utnam# 7. ( 44.). / naturalistic study of Dissociative Identity Disorder and Dissociative Disorder Eot>therwise 0pecified patients treated by community clinicians.Psychological Trauma: Theory, Research, Practice, and Policy, 1( )+!'L+@+.